BIOGRAPHICAL FORM 2018 SAMPLE 8/29/2017
■ ■ Did you complete a Bio Form in a previous HPE cycle? ■ ■
■ ■ Skip to Section XVII: Reapplicant Form ■ ■
Before going further, carefully read the
BIOGRAPHICAL FORM SAMPLE.
All entries must be typed.
To complete sections III and XVI, use an official or
unofficial transcript from each college you attended.
I. BACKGROUND INFORMATION
Have you previously applied to medical or dental school? Yes If yes, when? 2017
U.S. citizen or permanent resident? Yes
If no, country of citizenship:
Texas resident? Yes
If no, state of citizenship:
Ethnicity: Hispanic Native languages: English, Spanish
Other fluent languages:
What is your major at UT Dallas? BA Biology, Dance minor
Semester of graduation? Spring 2019
List the institution, year, and name of any degrees you have already completed. / attach 4x6 photo here
A business-like photo with your face clearly visible is most appropriate for HPE and for professional schools.
Most home printers cannot produce good quality
photos. Use a “photo printer” and “photo paper,”
or have a print made for $0.25 at most drug stores.
II. YOUR EVALUATORS
HPE participants must solicit 3 letters of evaluation (max 5), including two from science professors.
Evaluator Name / Position / Relation to You
III. ACADEMIC SUMMARY.
· Use your transcripts to enter hours and grades in the GPA Calculator at www.utdallas.edu/pre-health
· List all pre-college credits (i.e. from AP tests, dual credit courses) on the first line
· List all classes from all schools, including retakes.
Institution / Credits / Overall GPA / BCPMScience Credits / BCPM
Science GPA / at
www.utdallas.edu/prehealth/forms
AP Credit / 15 / 6
Richland Community College, 2015-2017 / 24 / 4.0
UT Dallas, 2017-present / 87 / 3.63 / 60 / 3.45
Total/Averages: / 126 / 3.69 / 66 / 3.45
IV. STANDARDIZED TEST SCORES
Include all past tests and planned future tests.
Medical College Admission Test (MCAT)Date / Total / Percentile / CPBS / Percentile / CARS / Percentile / BCLS / Percentile / PSBB / Percentile
1/2018 / 509 / 80 / 129 / 92 / 127 / 83 / 128 / 85 / 125 / 52
6/2018
“old version” MCAT score: BS:8 PS:10 VR:8 Total:26
Dental Admission Test (DAT)
Date / PAT / QRT / RCT / BIO / Gen. Che / Org. Che / Total
Sci / AC
Avg
V. ACADEMIC RECOGNITION
List academic honors, awards and other recognitions received since beginning college to the present. Indicate the Award Title, date received, city, country, state and a brief description of the award.
Activity/Honor / Description of Activity/Honor / DateOutstanding Student Researcher / Annual award for excellent research proposal, based on lab work and presentation to faculty. / 5 2016
Academic Excellence Scholarship / $1000/sem award for 8 sems, based on high school GPA & SAT / 8 2015
FSUW
FSUW
FSUW
FSUW
VI. NON-ACADEMIC RECOGNITION
List non-academic honors, awards and other recognitions received since beginning college to the present. Indicate the Award Title, date received, city, country, state and a brief description of the award.
Activity/Honor / Description of Activity/Honor / DateStudent Gov President / Elected for 2016-2017, based on service to campus and campaigning. <See Leadership> / 5 2016
/ FSUW
FSUW
VII. LEADERSHIP EXPERIENCE
List any leadership roles or positions of responsibility held since beginning college to the present. Indicate the Role Title, start date, end date, city, country, state and a brief description of the position.
Descriptions can be 300-characters long on TMDSAS.
Role Title / Description of Responsibilities(including “hours/week” and “hours total”) / Dates
From To
Student Gov President / Conducted monthly meetings of 60 student senators, oversaw 15 officers and completion of 18 projects to improve campus life incl. mental health awareness, stress workshops, improved crime reporting. Coordinated with university administration. / 5/2016 / 5/2017
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VIII. EMPLOYMENT
List all jobs (paid work experience) held since graduating from high school to the present, including military service. Indicate the employer, job title, when the job was held, start date, end date, city, hours worked per week, country, state and a brief description of the job.
Description length may be limited on TMDSAS.
Job Title / Where Employed and Responsibilities(including “hours/week” and “hours total”) / Dates
From To
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IX. RESEARCH ACTIVITIES
List any significant research activities (paid or volunteer) you have participated in since beginning college to the present. Indicate the Research Activity Name, start date, end date, city, approximate hours worked per week, total cumulative hours, country, state and a brief description of the research.
Descriptions can be 300-characters long on TMDSAS.
Role Title(include your responsibilities, “hours/week” and “hours total”) / Supervisor / Dates
From To
Green Fellowship – Planned and executed investigation of methamphetamine use on neural plasticity in mice. Designed experiments, coordinated research team. Measured 20 subjects (divided into 5 dosage levels) at learning tasks over 6 weeks, then dissected brains to assess plasticity using micropulse EEG. Findings presented to faculty and published locally. 40 hrs/wk, 640 hrs. / Dr. Inno Vater / S/2017 /
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X. HEALTHCARE ACTIVITIES
List any healthcare related community service, volunteer, employment OR shadowing experience you have participated in since beginning college to the present. Indicate the Activity Name, start date, end date, city, hours worked per week, total cumulative hours, country, state and a brief description of the activity.
Descriptions can be 300-characters long on TMDSAS.
Activity / Description(including “hours/week” and “hours total”) / Dates
From To
Shadowed Patch Emmup, MD / RHD Hospital burn ward; observed treatment methods & patient care. Discussed pathologies and treatments with the burn team. 15 hrs/wk, 60 hrs. as of 4/1/2018 / 2/2018 /
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XII. COMMUNITY SERVICE
List any non-healthcare related community service or volunteer activities you have participated in since beginning college to the present. Indicate the Activity Name, start date, end date, city, approximate hours per week, total cumulative hours, country, state and a brief description of the activity.
Descriptions can be 300-characters long on TMDSAS.
Activity / Description(including “hours/week” and “hours total”) / Dates
From To
Projects though AED / Assorted community service, esp. food drives. 15 hrs/sem, 30 hrs / 8/2017 / 5/2018
XIII. EXTRACURRICULAR AND LEISURE ACTIVITIES
List any significant extracurricular, leisure activities or hobbies you have participated in since beginning college to the present. Indicate the Type of Activity, start date, end date, city, approximate hours per month, total cumulative hours, country, state and a brief description of the activity.
Descriptions can be 300-characters long on TMDSAS.
Activity / Description(including “hours/week” and “hours total”) / Dates
From To
Wood carving / Hand carving small figures, mostly as a creative outlet. Avg 2 hrs/wk, max 10. ~500 hrs / 1/2015 / 5/2018
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XIV. PLANNED ACTIVITIES
Indicate future activities you plan on participating in between May 2016 and August 2017. This should include any future employment as well as any future research, healthcare, community service, or extracurricular activities. Indicate the Activity Type, start date, planned end date, city, total projected hours, country, state and a brief description of the activity.
Activity / Description(including “hours/week” and “hours total”) / Dates
From To
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XV. ACADEMIC DISHONESTY AND/OR CRIMINAL ACTIVITY
Describe any actions taken against you for academic dishonesty, conduct violations, or criminal activity (including felony and/or misdemeanor, other than minor traffic violations). Be as brief as possible while including relevant details and applicable dates.
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Health Professions Evaluation Biographical Form - Version 1.1
(10/9/2017) – Page 5 of 8
XVI. TRANSCRIPT and CHRONOLOGICAL SUMMARY
For each box, write the names of activities that you listed above.
DO note how many hours per week or month that you participated in each activity. / DO denote any series of one-time events (i.e. “community service through AED”)DO use abbreviations wherever you can do so clearly. / DO NOT denote one-time events separately
DO note where you took each class, if not at UT Dallas. / DO NOT list an activity in more than one column, even if you listed it in more than one section above. Instead, choose whichever column below is most appropriate.
DO include the letter grade for each class you took.
If you entered activities in the Leadership section of the Biographical Form, include them in the chart below. Choose whichever column best matches each activity.
Sem / school / Classes / Cred hrs / GPA / Healthcare or Research / Other Extracurricular / EmploymentF'05 / UTD / C- Chem I & lab A
A Macroecon.
A+ Col. Algebra
A RHET 1101
A RHET 1302 / 14 / 3.57 / Helped w/ billing for dad’s med. practice, 4 hr/month
Bollywood dance, 2 hr/wk
Community service, 22 hrs
S'06 / UTD/CCCC / A Intro. Mgmt. Acct.
B+ Chem II & lab A-
A+ Precalculus
A Dance Apprec. (CCCC) / 13 / 3.77 / Helped w/ billing for dad’s med. practice, 4 hr/month
Bollywood dance, 2 hr/wk
U'06 / SMU / A Am. Govt. (SMU)
A U.S. Hist. (SMU) / 6 / 4.00 / Helped w/ billing for dad’s med. practice, 4 hr/month
Bollywood dance, 2 hr/wk
F'06 / UTD/CCCC / A Bio I & wksp
B O.Chem I & lab A
A Calc I (CCCC) / 13 / 3.70 / Helped w/ billing for dad’s med. practice, 4 hr/month
Bollywood dance, 2 hr/wk / Receptionist, home healthcare agency, 5 hrs/wk
S'07 / UTD / A Intro. Fin. Acct.
A Bio II & wksp
A O.Chem II & lab A
A Calc II (CCCC) / 15 / 4.00 / Helped w/ billing for dad’s med. practice, 4 hr/month
Bollywood dance, 2 hr/wk
Young Muslims of North America, 4 hr/wk / Receptionist, home healthcare agency, 12-15 hr/wk
U'07 / Helped w/ billing for dad’s med. practice, 4 hr/month
Bollywood dance, 2 hr/wk
Young Muslims of North America, 4 hr/wk / Receptionist, home healthcare agency, 12-15 hr/wk
F'07 / UTD/CCCC / A Biochem I & wksp
A+ Phys for Bios. II & lab
A World relig. (CCCC) / 11 / 4.00 / Helped w/ billing for dad’s med. practice, 4 hr/month
Bollywood dance, 2 hr/wk
Publicity Comm Chair, Young Muslims, 4 hr/wk / Assistant Manager, home healthcare agency,
20 hr/wk
S'08 / UTD / A Fin. Info. Mgmt.
A Organizaton Behavior
A Bio lab
A Biochem II & wksp / 12 / 4.00 / Volunteer, nursing home, 8 hr/month since 3/08 / Helped w/ billing for dad’s med. practice, 4 hr/month
Bollywood dance, 2 hr/wk
Publicity Comm Chair, Young Muslims, 4 hr/wk
High school tutor, 3 hr/wk
Health Professions Biographical Form
(10/9/2017) – Page 8 of 8
XVII: 2018 Reapplicant Form – for reapplicants only
· Students who completed a Biographical Form during a past HPE cycle may skip to this section and complete it only.
· This form alone will count as their 2018 Biographical Form.
· If you completed a 2018 Biographical Form (sections I to XVI of this document), DO NOT complete this form.
Name: ______NetID: ______
BACKGROUND INFORMATION
Have you previously applied to medical or dental school? If yes, when?
U.S. citizen or permanent resident?
If no, country of citizenship:
Texas resident?
If no, state of citizenship:
Ethnicity: Native languages:
Other fluent languages:
What is your major at UT Dallas?
Semester of graduation?
Have you applied to medical or dental schools in a previous year(s)? ______When? ______
Did you receive an interview? ______If yes, where? ______
Did you ask medical or dental schools admissions staff for feedback about your application? ______
If yes, please summarize what you heard:
What have you done this past year to improve?
What do you plan to do this coming year?
Please list all coursework and grades earned that are not on your Biographical Form:
List any new MCAT or DAT scores since you last completed a Biographical Form.
Medical College Admission Test (MCAT)Date / Total / Percentile / CPBS / Percentile / CARS / Percentile / BCLS / Percentile / PSBB / Percentile
“old version” MCAT score:
Dental Admission Test (DAT)
Date / PAT / QRT / RCT / BIO / Gen. Che / Org. Che / Total
Sci / AC
Avg
Please list the names of those you have asked or will ask for letters of recommendation, and indicate whether the letter is already on file at HPAC from a previous application cycle:
______Already on file at HPAC?: ______
______Already on file at HPAC?: ______
______Already on file at HPAC?: ______
______Already on file at HPAC?: ______
______Already on file at HPAC?: ______
Describe any actions taken against you for academic dishonesty, conduct violations, or criminal activity (including felony and/or misdemeanor, other than minor traffic violations). Be as brief as possible while including relevant details and applicable dates.
Health Professions Biographical Form
(10/9/2017) – Page 8 of 8